Provider Demographics
NPI:1477955284
Name:JEAN, JACQUES (FNP-C)
Entity Type:Individual
Prefix:
First Name:JACQUES
Middle Name:
Last Name:JEAN
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5226 FIREBRICK LN SW
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-8807
Mailing Address - Country:US
Mailing Address - Phone:704-260-0037
Mailing Address - Fax:704-260-0037
Practice Address - Street 1:615 E 6TH ST
Practice Address - Street 2:STE 106
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28202-2918
Practice Address - Country:US
Practice Address - Phone:704-453-1444
Practice Address - Fax:704-260-0037
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-24
Last Update Date:2017-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5007327363L00000X
NCF0814732363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1477955284Medicaid
NCNCM669AMedicare UPIN